Minimally invasive techniques for transthoracic oesophagectomy for oesophageal cancer: systematic review and network meta-analysis.

BACKGROUND: Oesophagectomy is a demanding operation that can be performed by different approaches including open surgery or a combination of minimal access techniques. This systematic review and network meta-analysis aimed to evaluate the clinical outcomes of open, minimally invasive and robotic oesophagectomy techniques for oesophageal cancer. METHODS: A systematic literature search was conducted for studies reporting open oesophagectomy, laparoscopically assisted oesophagectomy (LAO), thoracoscopically assisted oesophagectomy (TAO), totally minimally invasive oesophagectomy (MIO) or robotic MIO (RAMIO) for oesophagectomy. A network meta-analysis of intraoperative (operating time, blood loss), postoperative (overall complications, anastomotic leaks, chyle leak, duration of hospital stay) and oncological (R0 resection, lymphadenectomy) outcomes, and survival was performed. RESULTS: Ninety-eight studies involving 32 315 patients were included in the network meta-analysis (open 17 824, 55·2 per cent; LAO 1576, 4·9 per cent; TAO 2421 7·5 per cent; MIO 9558, 29·6 per cent; RAMIO 917, 2·8 per cent). Compared with open oesophagectomy, both MIO and RAMIO were associated with less blood loss, significantly lower rates of pulmonary complications, shorter duration of stay and higher lymph node yield. There were no significant differences between surgical techniques in surgical-site infections, chyle leak, and 30- and 90-day mortality. MIO and RAMIO had better 1- and 5-year survival rates respectively compared with open surgery. CONCLUSION: Minimally invasive and robotic techniques for oesophagectomy are associated with reduced perioperative morbidity and duration of hospital stay, with no compromise of oncological outcomes but no improvement in perioperative mortality.

ANTECEDENTES: La esofaguectomía es una operación muy exigente que puede ser realizada a través de diferentes abordajes que incluyen la cirugía abierta o una combinación de técnicas con acceso mínimamente invasivo. Esta revisión sistemática y metaanálisis en red se propuso evaluar los resultados clínicos de la esofaguectomía abierta y de las técnicas de esofaguectomía mínimamente invasiva y robótica para el cáncer de esófago. MÉTODOS: Se llevó a cabo una búsqueda sistemática de la bibliografía de estudios que describiesen esofaguectomía abierta, esofaguectomía asistida por laparoscopia (laparoscopic assisted oesophagectomy, LAO), esofaguectomía asistida por toracoscopia (thoracoscopic assisted oesophagectomy, TAO), esofaguectomía totalmente mínimamente invasiva (totally minimally invasive oesophagectomy, MIO) o MIO robótica (RAMIO). Se realizó un mataanálisis en red de resultados intraoperatorios (tiempo operatorio, pérdida de sangre), postoperatorios (complicaciones globales, fuga anastomótica, quilotórax, duración estancia hospitalaria), oncológicos (resección R0, linfadenectomía) y supervivencia. RESULTADOS: Se incluyeron 98 estudios con 32.296 pacientes en el metaanálisis en red (abierta: n = 17.824, 55%; LAO: n = 1.576, 5%; TAO: n = 2.421, 7%; MIO: n = 9.558, 30%; RAMIO: n = 917, 3%). En comparación con la vía abierta, tanto MIO y RAMIO se asociaron con menos pérdidas hemáticas, tasas significativamente menores de complicaciones pulmonares, estancia más corta y obtención de un mayor número de ganglos linfáticos. No hubo diferencias significativas entre las técnicas quirúrgicas en las infecciones del sitio quirúrgico, quilotórax y mortalidad a los 30 y 90 días. MIO y RAMIO se asociaron con mejores tasas de supervivencia a 1 y 5 años respectivamente, en comparación con la cirugía abierta. CONCLUSIÓN: Las técnicas mínimamente invasivas y robótica para la esofaguectomía se asociaron con menor morbilidad postoperatoria y estancia hospitalaria, sin comprometer los resultados oncológicos, pero sin mejoría en la mortalidad perioperatoria.

Study protocol for a multicenter prospective cohort study on esophagogastric anastomoses and anastomotic leak (the Oesophago-Gastric Anastomosis Audit/OGAA).

Esophagectomy is a mainstay in curative treatment for esophageal cancer; however, the reported techniques and outcomes can vary greatly. Thirty-day mortality of patients with an intact anastomosis is 2-3% as compared to 17-35% in patients who have an anastomotic leak. The subsequent management of leaks postesophagectomy has great global variability with little consensus on a gold standard of practice. The aim of this multicentre prospective audit is to analyze current techniques of esophagogastric anastomosis to determine the effect on the anastomotic leak rate. Leak rates and leak management will be assessed to determine their impact on patient outcomes. A 12-month international multicentre prospective audit started in April 2018 and is coordinated by a team from the West Midlands Research Collaborative. This will include patients undergoing esophagectomy over 9 months and encompassing a 90-day follow-up period. A pilot data collection period occurred at four UK centers in 2017 to trial the data collection form. The audit standards will include anastomotic leak and the conduit necrosis rate should be less than 13% and major postoperative morbidity (Clavien-Dindo Grade III or more) should be less than 35%. The 30-day mortality rate should be less than 5% and the 90-day mortality rate should be less than 8%. This will be a trainee-led international audit of esophagectomy practice. Key support will be given by consultant colleagues and anesthetists. Individualized unit data will be distributed to the respective contributing sites. An overall anonymized report will be made available to contributing units. Results of the audit will be published in peer-reviewed journals with all collaborators fully acknowledged. The key information and results from the audit will be disseminated at relevant scientific meetings.